HomeMy WebLinkAboutMiscellaneous - 58 EVERGREEN DRIVE 4/30/2018 58 EVERGREEN DRIVE _
2l o Ja C :G0065 ppGfl.a
Commonwealth of Massachusetts
u F
City/Town of No. Andover .l7904')
a System Pumping Record ��
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other forms ENT
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. $.Y-9p Location:
on the computer,
use only the tab
key to move your Address
cursor-do not No. Andover — - - Ma
use the return —
key. City/Town State Zip Code
2. System Owner:
Name
iehan
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
IIII 3. Type of system: ❑ Cesspool(s) r9—Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
j 4. Effluent Tee Filter present? ❑ Yes ?rNo If yes, was it cleaned? ❑ Yes ❑ No
5. Conuition of ystem:
0-e 94-
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signat re f Ha le Da
7 ,
Signature f eceiving Facility Dat
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
I
A�lDOVER .. MAS
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RECEIVED
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A. FacIII In(o � a,p,,��L'.�n�,1�009�
(rr1�l�On TOWN.OFNORT
HEALTH DEPARTMENT
, SyS;°^
99
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., I ,�, l sy,a1em Owner,• � I' ��
.. i. •1 .'i',,I•` ••1'1/ Nf�r'�'�Y•I�'�'' �Y•�I 1J','•�I,�. " - '✓u-
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IF,UMP n� Record
• � ,{r �'t0,�11]/44�r ,� ,r S,tii�P,�s� rl ', •
DEP•.haa provided this form for use by local Boards of Health. The S stem�t�',ping•Record m 1st
be submitted to the local'Board of Health or other approving author(
A Facility Information r
7�-, unRortant. TOWN•OF NOR ria r<i R
rj,nwll8n
MIN out 1 System I.00atiOn HEALTH Cit �
M'Compuon hs!
ter,,uSe
only tha tab key Address
to move your-.;.-.
cursor•do
use the return....' ' City/Town Stat
Zip Code
,w ,
keySystem Owner,
Name ------------
Address(If different from location) .
I
Clty/Town , State• I'
977e—
Telephone-
7
Telephone Number
,;6.'':P.umo ping record
r.
(✓
ate of Pumpins 2. ua
Q n
t1 Pumped:
e
Dat ty p d. f
Gallons
'T Of system..,
Ypo . ❑ I . Cesspool(s)
Se tic Ta
n
��P k Tight
_ . ❑ g Tank
"'0 ther(descrlbej
4 Effluent Toe Filter present?.[] Yes. No If yes, was It cleaned? ❑ Yes ❑ No
5 Co�ditlon of 3 stgm�'
y ,
I Y.•lat}.rr
Sy -.ed By
T �G
CC ,,VehlGa Ucen a Number
t •yr yn4t fy ,trifYSrt, �IGw1r�l.. l i4` ,<. , ��. ,+F1Vj'Yyul
7 , S{ r °42 " '•,'.:r'rI'I r'1`7ti4 �'r•1 M144�1�'.I,�.til, +i l •, �
+'i�••�ri'f,iJ1!+ lyrflwy�°+l�+,1?Atirn�S!� ry•.;..,:{ •
7 Loca(on where contents yvere.dlsposed.
r !, t ,sbnature of Date
httpJtWwyv.mass,gov/dept.water/approvais/t5forms,htm#Inspect
•' Y
t5fonn4 doe 08/03 '- � •
System Pumping Record•Page 1 of t
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
X/6.
DA'Z'E OF PUMPING: -0-2- QUANTITY PUMPED /000 GALLONS
CE'S SPO0L: NO /YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
013SERVATIONS:
GOOD CONDI'T'ION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED 13Y: w
CO.N!IMI-NTS:
CO:NT!i'NTS TRANSFERRED TO:
Fir 'j
o FILE #_
r
-ITL.--EV INSPECTIONS
.iDean G. Luseomb II & Sons
,� a 4 P O. Box-135
Middleton, MA 01949
E 1-978=774-4065
' LICAENSED PLUMBER #20285
,rY•meq �� �"J - •j�/r
Fg
. i;t--_ .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
° PROPERTY OWNERS NAME.
ffi PROPERTY ADDRESS: MA
--�-
- - ADDRESS OF OWNER: --- h -----
(if different)
a DATE OF INSPECTION:
NAME OF INSPECTOR:
s l4
QUALITY IS NUMBER- ONE TO. US.
k
COMMONWEALTH OF MASSACHUSETTS
= EXECU'T'IVE OFFICE OF ENVIRONMENTAL AFFAIRS
' DEPARTMENT OF ENVIRONMENTAL PROTECTION
yy. DEAN G. LUSCOMB II
P.O. BOX 135
MIDDLETON, MA 01949
1-978-774-4065
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A .
CERTIFICATION
Property Address: EU
r
Owner's Name: �����
Owner's Address. $,gync
Date of Inspection:�J�� Azle e7/1,o)2
Name of Inspector: (please print)Baan G T u4rnmh II
Company Name;
Mailing Address: Sons
P-�. Rnx 1 'i5
MirlAlatnn MA (119 .0
Telephone Number: _o7R_77�_i:nSi
CERTIFICATION STATEMENT
I certify that I have personally inspected
the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:
ate: G
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health
or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer;if applicable, and the approving
authority.
Notes and Comments
""This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address }tow the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000
page 1
Dean G. Luscomb II & Sons
'
Page 2ofII P. O . Box 135
Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: `JS 0�re",kj Dr-I
/V, ed/`Cr" i'Y20-
Owner:
Date of Inspection: 2/ zooZ
Inspection Summary: Chec A, ,C,D or E/ALWAYS complete all of Section D
A.. System Passes:
V I have not found any information which indicates that any of the failure criteria described in 310
CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass,
Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
NThe septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structural)
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved
b thea
Board
of Health.*A
metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicatingthat the tank P
is less than 21 years old is available.
ND explain:
NObservation of sewage backup or break-out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
A-JThe system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3of11 Dean G. Luscomb II & Sons
P . O . Box 135
Middleton, MA 01949
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM S
PART A
CERTIFICATION(continued)
Property Address:
f
Owner: �o
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, '
system is functioningin a PP > if an determines
manner that r mines that th
at protects the public health,safety and environment: e
N The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface
� 1water supply or tributary to a surface water supply.
1 The system has a septic tank and SAS and the SAS is within a Zone 1 of a u
� p blic water supply.
The system has a septic tank and SASand the SAS is within 50 feet of a private water supply I PP y well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet
private water supply well**. Method used to determine distance or more from a
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile or compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form,
3• Other:
3
Dean G. Luscomb II & Sons +
Page4of11 P . O . Box 135 '
Middleton, MA 01949
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTSS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 5F Cyer recn jar
Owner: Vo-1 le,
Date of Inspection: S aolvz
D. System Failure Criteria applicable to all systems:
You must indicate"yes" or"no"to each of the following for ali inspections:
Yes No
N Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool i
s less than below Invert or available volume is less than V2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
�} Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Yes/No)The system fails. I have determined that one or more
of the above bove failure criteria exist as
described
to 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure,
9. Large
TSystems
consideredao :
large system the system must serve a facility with a design now of 10,000 gpd t,1-5-,000
gpd•
You must in t e either`yes"or"no"to each of the following:
(The following trite ' ply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet urfacedri'
nking w pP1Y
— _ the system is within 200 feet of a to ace drinking water supply
the system is Iota
Zone II oa nitrogen sensitive area(Interim ead Protection Area—I WPA)or a mapped
f lic water supply well
If you a answered "" esto any y question in Section E the system is considered a sign an threat, or answered
in Section D above the large system has failed. The owner or operator of any large sys considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance h 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
i
Page 5ofII Dean G. Luscomb II & Sons
P . O . Box 135 ,
Middleton, MA 01949
8-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
i ' �4
Date of Inspection: S / ZcKiZ
Check if the following have been done. You must indicate "Yes" or"no,,as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks ?
✓ _ Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of this inspection ?
L/ p coon .
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facilitydwelling or Ming ins ected
for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components,P , excluding the SAS, located on site?
_ Were the septic tank manholes uncovered, opened, and the interior
of the baffles or tees,material of construction, dimensions, depth of liquid, depth of slof e udge and depth of scumk inspected for the s?ition
_ Was the facility owner(and occupants if different from owner)provided with informat'
maintenance of subsurface sewage disposal systems ? don on the proper
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
no
V _ Existing information. For example, a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part.0 is at issue a
is unacceptable) [3 10 CMR 15.302(3)(b)) pproximation of distance
I
5
Dean G. Luscomb II & Sons
Page 6 of 11 P. O . Box 135
Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Eu Y' P r
Owner: j l e
Date of Inspection: q�Z
RESIDENTIAL FLOW CONDITIONS
Number.of bedrooms(design): 3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):
Number of current residents:—�L
Does residence have aarba e
g g grinder �e or no �S
Is laundry on a separate sewage system (yes o no. NO[if yes separate inspection required)
Laundry system inspected (yes ox:D tLo
Seasonal use: (yes o<@::10-Jo
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes o1Q, W
Last date of occupancy: Cu�e.,-
MERCIAL/INDUSTRIAL
Type o lishment:
Design flow(ba 310 CMR 15.203): g„d
Basis of design flow(seats /sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yesoar
Non-sanitary waste discharged fle 5 system(yes
Water meter rea ' , ' vailable: —'
Last occupancy/use:
OTHER(describe):
i
GENERAL INFORMATION
Pumping Records
Source of information:Tek etS
Was system pumped as pan or the ins ecUon ` '
P y�dr no):
If yes,volume pumped:gallons--How was quantity pumped determined? R,r� ,
Reason for pumping:_��,,'�� _
TYPE OF SYSTEM
1/Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
_Privy
Shared system(yes or no)(if yes, attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components, date installed(if known)and source of information:
47 / �" lked tZ� er 6scsra (�
Were sewage odors detected when arriving at the site(yes o no A—)o
6
Dean G. Luscomb II & Sons
Page 7 of 11 P . O . Box 135
Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: '1-9 Eve ,n -D
d-71��ILOVL�-f- ,
Owner:
Date of Inspection: SoZl 2667—
BUILDING
6jZBUILDING SEWER(locate on site plan) Yes
Depth below grade:
Materials of construction:_cast iron _✓40 PVC other,? in);
Distance from private water supply well or suction line:
Comments(on condition of joints, venting, evidence of leakage, etc.):
R%r. aid --� .a - c-QA I% z� Lookg
SEPTIC TANK:7 locate on site plan)
Depth below grade:,jR S
Material of construction: foncrete metal
—other(explain) .,e% � _fiberglass_polyethylene
If tank is metal list age..6?, Is age confirined by a Certificate of Compliance
certificate) (yes or no): a copy of
Dimensions: S SIJ ►�X 5.`4W"4&
Sludge depth: <2 w
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: G
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:_ "y s `� 4S a
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert eviden f leakage, etc.);
C3 a6
e�s "
0� + °� ► �� '��.�.
EASE TRAP:W(locate on site plan)
Depth belo�constru
_
Material ofeia.�_concrete_metal fiber lass
(explain): �,,A — g _polyethylene_other
Dimensions: �,, �
Scum thickness: m.d_�----•- -- "
Distance from top of scum to top of outlet tee or '"o "" � �
Distance from bottom of scum to bo .
`Date of last pumping: outlet tee or baffle: ire
Comments on - � �
( int recommendations, inlet and outlet tee or baffle condition, s s rat integrity, liquid levels
r e outlet invert, evidence of leakage, etc.):
Dean G. Luscomb II & Sons
Page 8of11 P . O . Box 135
Middleton, MA 01949
1-9
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS 78-774-4065 406s TS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: v�� � �r
Owner: VO-Ile-
Date
O-IleDate of Inspection:
T GHT or HOLDING TANK: R=(tank must be pumped at time of inspection)(locate on siteplan)
Depth below
Material of construction: oncrete metal fiberglass9I
o .eth ane other(explain);
---- ,1y
Dimensions:
Capacity:. 01 ns �
Design Flow: gallons/day
Alat ni p• nt(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on siteplan)Z-i3o1S
Depth of liquid level above outlet invert:zo— e1 'D-ac's
Comments(note if box is level and distribution to outlets equal, any evidence of solids c
leakage into or out of boxz etc,); arryover, any evidence of
PL3 P CHAMBER: (locate on site Plan)
Pumps in working or 23�or,�O :
Alarms in working"
C.o,rnmen"ffinote condition of pump chamber, condition of_m sbid-a
P P Ppkttte„nances, etc,):
8
I
Dean G. Luscomb II & Sons
Page9of11 P . O . Box 135
Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: S /
SOIL ABSORPTION SYSTEM (SAS): Yl?S(locate on site plan,excavation
not required)
9 )
If SAS not located explain why:
4 5���` QNCI Zkc,l,zwt,,,-
Type
leaching pits, number:_
leaching chambers,number:
leaching galleries,number:
Y leaching trenches, number, length: -/ - T-er. c4ej
leaching fields, number, dimension
overflow cesspool,number: ?e� ,2+'�
- "��s•
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
n roZfeills
CESSPOOLS: (cesspool must be pumped as part of inspect ion)(locate on site plan)
Number an uration:
Depth-top of iAvert:
liquid to '
E-
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater in yes or no):
Comments(note coni ' of soil, signs of hydraulic failure, level of ponding, condition of v g atinketc,):
PRIVY:�(locate on site plan)
Materials o`I'conspvction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of h ''
user level of ponding, condition of vegetation, etc.):
I
9
Dean G. Luscomb II & Sons
• Page l0 of 11 P. O . Box 135
Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ,SFS -Fve/Cjr•G,e� r,
Owner:
Date of Inspection: �
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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Dean G . Luscomo LL & Susi
Page I 1 of 11 P . 0 . Box 135 ,
Middleton, MA 01949
1-978-774-4065
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: h Eoezreen Or.
Owner: L/6.111--
Date of Inspection: S d/ 200-L
-SITE EXAM
,.-FE
Slope Se
✓Surface water Ove/QUO 4,11
k-/Check cellar `b rM Wy Su rs%p r gyp,
✓Shallow wells P0Me-
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS
Checked with local Board of Health-explain: Na ire S p�
Checked with local excavators, installers (attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
law qrack 0� 14,11
V I LO CIA
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
r DATE: -o
r SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example: left front of house)
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PATE,OF PUMPING: y I QUANTITY PUMPED / GALLONS
CESSPOOL:. NO_ YES S.EPTIC TANK: NO YES
t
NATURE OF SERVICE: ROUTINE w EMERGENCY
L'. OBSERVATIONS:
GOOD CONDITION FULL TO COVER.
4 , HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
t
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
PUMPED BY:.
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COMMENTS• ,
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Adcclres fJF e6 �If/ tJ Title of File
Page of
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes
action Document/ document/
Num. Action Department
Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building Department
i
Lot 7 Ebergreen Drive
Richzrd Valle
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION I
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
Lot 7 Evergreen Drive I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum !
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of 1000 in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of 200 lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia. ) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be .maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE 4/12/71
8ignatdre of Appli
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE 4/12/71
Signa,, re of ealth Agent
I have inspected the uncovered system indicated above and find everything done
as described.
J
DATE
Signature ofi nspecting Officer
Percolation Test 7 Minutes Soil: Clay
Garbage Grinder
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, -MASS.
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D-
No
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1. NAME_ 1,-Veh t1W G L t DATE ,&/f l/—
2. ADDRESS lVa 401►, LOT NO. J TEL. —
3. NO. OF BEDROOMS DEN YES NO��
4. GARBAGE GRINDER YES _ NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM T6iy� !s/�TE/Q
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE; LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE4/12 al,,
NAME OF APPLICANT Richard Valle
LOCATION Lot #7 Evergreen Drive
Address of lot no.
BUILDING: Dwelling x Other
SYSTEM: New Repair
GENERAL DESCRIPTION OF LAND high
SUBSOIL: Clay____ Gravel Sand
PERCOLATION TEST 7 minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 1,000 gallon capacity.
LEACH FIELD 200 lineal feet of drain pipe,
William J, D scoil, Engineer
Board of Hea h
I
.777777777t777__
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QUANTITY r'UMpCo
C � »I'UUtr �•N0 � YES. SEPTIC' TANK; NO.- Y E t,
RE. OF SER`YLCE""'ROUTINE. EMFRCENCY
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4DRESI
r RTH .AN I��.-.�V ER SYSTEM UMPING RECORD AUG 0 9 2004
DA'I-E
TOWN OF NORTH ANDOVER
LM
HEALTH DEPARTMENT
SYSTEM OWNERSYSTEM LOCATION
vo�I�
5S �V � ROiv6 ,�Duse
No r� O
DA TE OF PUMPING: - T -___----QUANTITY PsJ[vEI�ED°
CESSPOOL, NO YES Sept;;l'an*: .>
NATURE:OF SERVICE: RO JI` ME /EMERGENCY
OBSERVA'rIONS:
GOOD CONDITION E'tlE
_�TOCOV .�R
HEAVY GREASE BAFFLES IN PLACE
ROOTS -- LEACHFIELD RUNBACK
EXCESSIVE SOL)DS FLOODED -
-SOI-ID CARRYOVER OTHER EXPLAIN ---
System Puanpr:d by
COMMEN-I-S.
-._._....- ..... _. ---- -
CON I EN FS FRANSFE RRI D'I't�
No Andover J&S Development dba
1600 Osgood St Stewart's Septic
Building 20 Suite 2-36 Andover Septic
No. Andover, Ma 01845 58 South Kimball Street
Bradford, MA 01835 REMY
MAY 18-2012
TOWN OF NORTH ANDOVER
Date Name & Address Gallons Comments HEALTH DEPARTMENT
5-Apr Andriolo 37 Birch Lane 1500 Good
Sullivan 47 Boxford St 750 Good
6-Apr Saplenza 40 Sterling Ave 1500 Heavy bottom
9-Apr Disalvo 400 Winter St 1500 Good
10-Apr Sarano 265 Hay meadow Rd 1500 Xxxsolids
12-Apr Lind 575 Winter , Iort., 1500 Good
16-Apr Distefano 46&Raleigh Tavern Lane 1000 HG
Walsh 58 Paddock Lane 1500 Good
18-Apr Schrader 35 Woodberry Lane 1000 Good
Ahlhdm 48 Hawkins Lane 1000 Good
19-Apr Barrett 235 Candel Stick Rd 1500 Good
20-Apr Harold 453 Forest St 1500 Good
Duffy 67 Shirwood Dr 1500 Good
Zoll 333 raeligh Tavern Lane 1500 Good
- affeers Car a 564 Chickering Rd 2000 red tank
25-Apr Valle 58 Ever reen 1000 Good
27- pr ucas 39 deer meadow Rd 1500 Good
30-Apr Meaney 745 Foster St 1000 Good